经外环口以下途径显微镜下精索静脉结扎术治疗精索静脉曲张术后复发的疗效分析

目的:分析精索静脉曲张(VC)术后复发的病因，探讨经外环口以下途径显微镜下精索静脉结扎术(MV)治疗复发VC的疗效。方法:回顾性分析2015年4月至2019年4月青岛大学附属医院收治的16例VC术后复发患者的病例资料。中位年龄27(18～36)岁。5例既往曾行精索内静脉高位结扎术，11例曾行腹腔镜精索静脉结扎术；16例...

Analysis of the cause of varicocele recurrence and the application of sub-inguinal microsurgical varicocelectomy in recurrent varicocele

Objective To analyze the cause of varicocele(VC)recurrence and investigate the efficacy of sub-inguinal microsurgical varicocelectomy(MV)for recurrent VC.Methods All of 16 inpatients diagnosed as recurrent VC,in the Department of Andrology of the Affiliated Hospital of Qingdao University from 2015 April to 2019 April,were performed sub-inguinal MV.The age of the inpatients was 18-36 years old,median 27 years old.5 cases were originally performed retroperitoneal high ligation of spermatic vein and other 11 cases were originally performed laparoscopic varicocelectomy.During the review one to three years after the previous operation,all of 16 patients were diagnosed as VC recurrence.The complains of these patients during the review included male subfertility(10 cases)and scrotal pain(12 cases),in which 6 cases’complains were male subfertility with scrotal pain.After admission,13 patients were classified as GradeⅢ(left in 8 cases,bilateral in 5 cases)and 3 patients as GradeⅡ(all left).The median of their visual analogue scale(VAS)was 2.5.Color doppler flow imaging(CDFI)grading showed:GradeⅢin 12 cases(left in 7 cases,bilateral in 5 cases),GradeⅡin 4 cases(all left).Particularly,12 of them were Graded asⅢsimultaneously accompanying with Nut-cracker Phenomenon(NCP).Preoperative tests showed that the average serum testosterone was(16.2±4.9)nmol/ml,the average sperm concentration was(11.8±3.9)×10⁶/ml and the progressive motility rate(PR)was(24.4±4.2)%.All of the patients were performed sub-inguinal MV using general anesthesia and supine position.The spermatic cords were clearly exposed and padded up by inserting gauze strips under them.During the operation,the field was magnified 4-6 times with the microscope.Then all of the dilated external and internal spermatic veins were ligated,at the same time the internal spermatic artery and lymph vessels were well preserved.During these operations,11 patients underwent left-side MV,while other 5 did bilateral MVs.During these MVs,we found twisted and dilated external and internal spermatic veins in all cases and well preserved the internal spermatic arteries and lymph vessels.The number of ligated left and right external spermatic veins were(2.1±0.6)and(1.4±0.5)respectively and the number of ligated left and right internal spermatic veins were(10.1±1.1)and(6.6±0.5)respectively.We also found out(1.3±0.5)internal spermatic arteries and(3.0±1.0)lymph-vessels on left side.On right side,there were(1.4±0.5)internal spermatic arteries and(2.6±0.5)lymph-vessels respectively.At last,we summarily analyzed the pre-operative and post-operative VAS,serum testosterone,CDFI and semen analysis data.Results All of the 16 sub-inguinal MVs were successfully performed.All patients were reviewed comprehensively 6 months after MV.The reviewed results showed that the post-operative VAS was significantly reduced(Z=-2.994,P<0.05),palpable scrotal vessels disappeared and Valsalva tests were negative.No obvious reflux of internal spermatic veins were detected by CDFI.Interestingly,the sperm concentration and motility were both significantly improved 6 months after MV(P<0.05),while there was not remarkable increase of the serum testosterone after MV(P>0.05).During the follow up,no testicular atrophy,hydrocele and other complications were found.Up to submission,five of the ten patients who presented for male subfertility have impregnated their wives.Conclusions The most possible cause of VC recurrence could be the omission of the external and internal spermatic veins,particularly in the gradeⅢVC patients or VC accompanied with NCP.The sub-inguinal MV,which can discover more twisted spermatic veins and at the same time preserve the spermatic artery and lymph-vessels,shows better clinical efficacy than other procedures.